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Online Health Chat with Dr. Leonard Horwitz

June 25, 2012

Introduction

Cleveland_Clinic_Host: Many medical conditions that lead to anemia affect the whole body in general, including iron and vitamin B12 deficiency, chronic inflammation, and even general weakness from other medical conditions. Treating just the anemia may not cure associated symptoms, such as fatigue, weakness, headache, or shortness of breath. Understanding the relationship between anemia and general health will lead to better awareness of treatment choices and expected outcomes.

Anemia is one of the most common medical problems, affecting about 5% of the population and up to one-third of hospitalized patients. Although blood loss and inadequate nutrition account for much of this, the causes are more widespread. Additionally, there may be more than one explanation for a particular person’s anemia. People with chronic illnesses, such as kidney disease, malignancies, chronic infections, and arthritic conditions often are affected. Almost everyone will develop some degree of anemia after surgery or acute illness. Others are anemic due to inherited problems. Many of these medical problems will produce symptoms which overlap those associated with anemia, such as fatigue, weakness, and headache. Therefore, the widespread tendency to prescribe iron and/or vitamin B12 or to use “erythropoietic stimulating agents” (ESAs), such as Procrit® or Aranesp®, may not be the best or only approach.

Red blood cells contain hemoglobin, a protein which carries oxygen from the lungs to supply the rest of the body. Red cells, like everything else in the body, have a natural life span, after which they are broken down and recycled. For a red cell, the life span is about 4 months, and blood loss shortens this span. Anemia is a result of reduced production of these red blood cells or the hemoglobin protein, increased loss or destruction, or combinations of each of these. Very commonly, a person may be losing blood gradually and consistently, such as that associated with menstruation, colon polyps, or an inflamed stomach. Inflammation, infections, and many autoimmune conditions, in which the body becomes sensitized to parts of its own self as if it were an outside infection, will damage red cells and shorten their life span. They may become trapped in the spleen, which is the body’s blood filter.

Reduced production of red cells may result from low raw materials, such as iron, vitamin B12, or protein. Problems with the intestine may prevent these from being absorbed properly. There may be an inherited problem in making enough of the right kind of hemoglobin. In addition, the bone marrow, the site of production of blood, may not be making enough red blood cells because the bone marrow itself may have an internal problem interfering with production. Another possible reason is the bone marrow may be getting improper chemical signals from a body that is stressed with illness and, in turn, instruct it to slow down. Many medications also slow down the production.

A thorough examination may pick up features of certain types of anemias or indications of other diseases. Blood tests used to evaluate anemia try to distinguish between these different causes. They also can pick up diseases in other body organs. In the last decade or so, we have learned much more about how the body controls absorption and disposition of iron. We have been able to use this information in getting a more accurate picture of certain problems with anemia. There are also mutations in certain proteins involved. Occasionally, one has to examine the bone marrow itself to find out what is going wrong. In this way, the doctor may direct the person suffering from anemia to the proper treatments, and instruct him or her on expectations.

About the Speaker

Leonard J. Horwitz, MD, is on Staff in the Department of Hematologic Oncology and Blood Disorders at Cleveland Clinic Main Campus. He accepted that appointment in 2007. He had been an assistant professor of medicine in the Section of Bone Marrow Transplantation at The University of Texas MD Anderson Cancer Center in Houston, TX from 1984 to 1989. He thereafter entered private practice in hematology/oncology in Cincinnati, Ohio until coming to Cleveland Clinic. He served as director of the bone marrow transplant unit for Jewish Hospital of Cincinnati from 1989 to 2003. His clinical interest lies in non-malignant blood disorders.

Dr. Horwitz graduated magna cum laude from Yale University in New Haven, CT, and received his medical degree from Albert Einstein College of Medicine, Bronx, NY. He completed a residency in internal medicine and fellowship in hematology at Long Island Jewish Hospital, New Hyde Park, NY. Dr. Horwitz completed a second fellowship in medical oncology at The University of Texas MD Anderson Cancer Center in Houston, TX. He is licensed to practice medicine in Ohio.

Dr. Horwitz is a member of the American Medical Association, American College of Physicians (fellow), and American Society of Clinical Oncology, among others. He is board-certified in hematology and in medical oncology, and by the American Board of Internal Medicine.

To make an appointment with Leonard Horwitz, MD, or any of the other specialists in our Taussig Cancer Institute at Cleveland Clinic, please call our Cancer Answer Line from 8 am – 5 pm EST at 216.444.HOPE or call toll-free at 866.223.8100. You can also visit us online at www.clevelandclinic.org/cancer.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic expert Dr. Leonard Horwitz. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.

Anemia and Cancer

annblank: I have been anemic my entire life, and also take folic acid/ferrous sulfate/vitamin B12 supplements weekly. I had tumor reduction surgery and HIPEC (heated intraperitoneal chemotherapy) at Cleveland Clinic in September 2011 to remove generous portions of my digestive tract. Now I am more anemic than ever, and less able to easily digest greens and proteins. I also experience small bowel obstruction. What can I do?

Dr__Horwitz: I certainly hope your fight against cancer continues to meet with success. I cannot say what problems existed beforehand, but there are now two aspects to your anemia which may be helpful to discuss.

One is the reduced ability to absorb iron, as well as vitamin B12 and other nutrients, after intestinal procedures. The oral route may not work well at all, and one may have to be monitored for the need for intravenous iron, B12 injections, etc.

The other is that people with ongoing illnesses, such as cancer or renal failure, have been shown to do better with iron supplementation by vein. Erythropoietin (Aranesp®, Procrit®, and Epogen®) in these situations can help too, but this has to be decided individually.

annblank: Okay, that does help. Thank you.

Dr__Horwitz: Glad I could help. If you would like to discuss this more, the number to the Cancer Answer line, which we hematologists at the Cleveland Clinic also use, is on the top of the blog.

Hemolytic Anemia

ozzie: My daughter was diagnosed with hemolytic anemia. She had a bone marrow biopsy, and needed two units of blood. She started out on 80 mg of prednisone and is now down to 30 mg per day. Blood work at 80 mg and 60 mg was normal. Now her platelets are dropping, but they do not know why. This all started after her twins came down with hand, foot, and mouth disease, and the 5-year-old had strep throat. Any thoughts or ideas would be appreciated. We are in Toledo and could come to Cleveland Clinic. Thanks so much!

Dr__Horwitz: I hope your daughter meets with success in having the hemolytic anemia treated. This means that the red blood cells break down more quickly than they should. Often, this is because of antibodies in the system against the red cells. As with your daughter, there may be antibodies to other cells, such as platelets, and her doctors are probably checking for still other organ systems which may be affected.

Prednisone is one of many medications used to control this and is one of the more effective, but we like to minimize its use due to long-term side effects.

You are right, we do not know what brings hemolytic anemia on, but we do suspect that exposure to viruses or certain bacterial infections might lead to problems.

Anybody who wishes to have a referral can call the Cleveland Clinic's Cancer Answer Line (at 866.223.8100). They also handle our hematology consults even when it is not cancer.

Anemia and Menopause

Summer2012: I was recently diagnosed with anemia. I am concerned as my father died of chronic lymphocytic leukemia, and I always worry about my blood work. Could this fairly “severe” case of anemia be resultant of prolonged, heavy periods because of perimenopause?

Dr__Horwitz: The most common reason for a woman approaching menopause to become anemic would be uterine blood loss, followed closely by losses from the intestinal tract. Both should be checked.

CLL (chronic lymphocytic leukemia) affects a line of blood cells not related to the red cell production line, and only rarely have there been cases in the same family. Most people with CLL are not anemic, though this can occur in latter states.

Ferritin Levels

FORQUER: My ferritin level is 12. How high can I raise it?

Dr__Horwitz: There are a number of appropriate oral iron supplements available. Choose one with 325 mg iron sulfate (or 65 mg elemental iron). This is a good place to start. More important is to find out where you are losing your iron and have that addressed. Ferritin is a protein found in the body that allows it to store iron. A ferritin test measures the amount of iron in your blood. The normal ranges for males is 12 to 300 ng/mL and in females 12 to 150 ng/mL. A lower ferritin number indicates that the person does not have enough ferritin in their body.

jodo: I have had anemia for many years. My last ferritin tested at -1. I am scheduled for intravenous therapy. Will this help? I am tired of feeling weak. I am having heart palpitations and trouble breathing. If these don’t work, what treatment would be next?

Dr__Horwitz: Anemia will bring out other medical problems, such as the ones you are experiencing. Iron replacement, as was recommended to you, is necessary. It may be necessary to have more infusions than originally planned to "fill your tank." Again, I hope your doctors are able to find where you are losing the blood.

Interestingly, people who are very iron deficient may have trouble absorbing oral iron! Intravenous treatments may get them to a point where they may start using oral treatments.

Mental Health and Anemia

clotto: Is depression a by-product of anemia?

Dr__Horwitz: I have not heard of a direct connection, but certainly the fatigue and fall in activity level can get someone depressed! I hope things work out for you.

bernie: Does or can anemia or medications for anemia cause neurological problems?

Dr__Horwitz: Anemia can lead to some mental fogginess and fatigue. There are many causes of anemia, and some of the underlying problems require treatments that may cause neurological problems. Please have your doctor check your medications and see if that could be a cause.

Anemia of Chronic Disease

nancyhanks: What is the best way to confirm a diagnosis of anemia of chronic disease?

Dr__Horwitz: It is what we call a "diagnosis of exclusion." We make sure there is no other obvious cause. We can get hints; other routine blood tests may show evidence of chronic problems with another organ system that may lead to anemia. Sometimes we have to go all the way to a bone marrow examination if it is not clear.

Foods, Medications, and Iron

mh9684: I am 27-years-old and have been taking Nexium®, Dexilant®, or other stomach medicines for about 10 years. In the past few recent years, I have become iron-deficient anemic. Could these medicines contribute to an inability to absorb these? I always take the iron supplements I'm on at almost 12 hours apart, so they should be absorbing properly.

Dr__Horwitz: There are a number of medications and foods which interfere with iron absorption. It is best to avoid taking iron an hour before and up to two hours after a meal. Your pharmacist can let you know which of your medications can interfere.

annblank: Are certain foods or nutrition still considered to be valuable sources of iron, or in treating anemia?

Dr__Horwitz: Liver and beans are two which come to mind. Neither has enough to treat somebody who already is significantly iron deficient.

floot: I read a review that chronic use of heparin or warfarin, can cause anemia. Is this true? If so, would does one do about it? Are there other medicines besides heparin and warfarin?

Dr__Horwitz: These medications are used to prevent blood from clotting as quickly for people who have had blood clotting problems or need to prevent them. This means that it will be easier for them to bleed internally. I will stress again how important it is to strike a balance between the desired effects of a medication and its side effects.

annblank: So back to blood clotting, if one is using a blood thinner such as Lovenox®, would that would contribute to anemia? Dr__Horwitz: Any medication which would prevent unnecessary and dangerous blood clots will prevent some that are needed. People on Lovenox® or any other blood thinner—including aspirin—should be watched for signs of blood loss, which may be subtle.

Blood Tests and Other Diagnostic Tests

nancyhanks: What can be learned from a peripheral blood smear as well as CBC (complete blood count)?

Dr__Horwitz: We can tell by the size and shape of the red cells whether we should suspect iron or B12 deficiencies, or it might look like the red cells are being broken down (hemolyzed). Looking at the other cells may give us a hint of an underlying bone marrow problem.

nancyhanks: What can one expect in the complete blood count after one IV iron infusion?

Dr__Horwitz: It would depend how iron deficient the person was in the first place. Usually, it takes three or four infusions to see a difference. If there are other illnesses present, it may take longer to respond.

nancyhanks: Would swallowing the camera for an upper GI (gastrointestinal) bleed be more diagnostic for anemia than other tests in long-term anemia presentation?

Dr__Horwitz: Each test looks at something different. Since we can't reach the small intestine with a scope, this is how we try.

Medical Conditions and Anemia

SueM: After a diagnosis of polymyalgia rheumatica I ended up severely anemic. Is there a relationship between the two? Is there a relationship with being treated with long-term prednisone?

Dr__Horwitz: People with rheumatologic diseases may indeed become anemic. Often, there may be antibodies against the red cells. Just as often, they may have an associated "anemia of chronic disease." The body directs its energy elsewhere when under attack and may allow some degree of anemia.

An additional problem of long-term prednisone use is irritation of the stomach lining, which can lead to blood loss. This should be monitored. There is always a balance that has to be struck between a medication's helpful effects and its side effects.

nancyhanks: Can a diagnosis of ITP (idiopathic thrombocytopenic purpura) be confirmed from bone marrow?

Dr__Horwitz: We are getting off topic, but you are nice enough to join in today. Often the appearance of the platelets on a peripheral smear will help us make the diagnosis, with the rest of the clinical picture.

hmg1212: My 19-year-old daughter was diagnosed with anemia last fall. She is a college student living away from home. Her nutrition isn't the best. She has recently been diagnosed with anxiety and supraventricular tachycardia (SVT). Can this all be related?

Dr__Horwitz: I think I get anxiety and SVT from my kids living away at college, too! I hope she is doing well with her studies. Even with "poor" nutrition, her doctors will be looking at other causes, particularly blood loss. Severe anemia can lead to other symptoms such as anxiety and rapid heart beat.

FORQUER: Can bleeding from hemorrhoids cause anemia?

Dr__Horwitz: If it goes on long enough, sure. However, I would have a colonoscopy to make sure it is just the hemorrhoids.

jello: Why and how does one develop anemia if they have cirrhosis? Or are they totally separate conditions? Also can either affect breathing (oxygen absorption)?

Dr__Horwitz: Cirrhosis leads to a number of blood problems, and I am afraid there is too much to discuss on that topic for our format today. Please feel free to contact me if you wish for more details. You may call the Cancer Answer Line, which serves hematology also.

louise: What is the relationship between anemia and restless leg syndrome?

Dr__Horwitz: I really don't know.

jonto: What medical disorders cause anemia?

Dr__Horwitz: It is said that, "Hematology is the study of blood and all the organs through which it flows." This is a very good and broad question, but to answer it completely, I may have to charge you tuition!

hands_up: Can you talk about anemia and bleeding ulcers?

Dr__Horwitz: Bleeding ulcers can lead to anemia if left unattended. Losing red cells through bleeding leads to losing the iron in them that would have been recycled.

clough: What disorders does anemia make more complicated or even cause?

Dr__Horwitz: To start, anything which requires oxygen to be transported: cardiac problems, circulation problems (including to the brain and legs), and breathing problems. If anemia is serious enough, most organ systems can suffer. In addition, iron deficiency itself can affect the skin, the intestinal tract, muscles, etc.

Aging and Anemia

nancyhanks: Aging and bone marrow. Does it just give up?

Dr__Horwitz: There is no clear correlation with anemia and age, but there is more "myelodysplasia" (let’s define it for here as bone marrow inefficiency) as one gets older. How and if it is treated depends on its severity.

Anemia and Menstruation

jackie: What is the connection between anemia and menstrual bleeding?

Dr__Horwitz: As one loses blood, the iron in the red cells that would have been recycled gets lost, too. That is how blood loss makes people iron deficient.

nancyhanks: Would eliminating menstrual blood loss with birth control help the anemia?

Dr__Horwitz: This is done sometimes, generally straight progesterones and primarily to stop the bleeding, which in turn would help the anemia.

Iron Infusions

Summer2012_1: Is there anything else I need to ask the gynecologist about my blood work because from what I am reading it seems that IV (intravenous) iron is more easily absorbed than oral iron. I really want to feel better as quickly as possible. I want to be sure this is an issue that can be turned around quickly.

Dr__Horwitz: There are some downsides to taking iron IV, such as allergic reactions and phlebitis. This is not to mention the time involved, an hour or two for as many as eight or more sessions, depending on what preparation is used. Although these effects usually are not severe, if taking iron orally is tolerated and effective, it is preferred. It may take some weeks to have its full effect.

Dr__Horwitz: We generally use "transfusions" for blood products and "infusions" for medications, such as intravenous iron.

howard: After medications didn’t work, I have finally been told that I will need to have iron infusions (I think that is what the doctor called them) and, depending on how well it works, that will determine how many I will need. What should I expect? Will I be able to go back to work right away? Will I feel sick? Any feedback would be helpful. Sorry if I am being a little repetitive. I signed on late and don't know if you already answered this!

Dr__Horwitz: Any treatment has its side effects, and in the case of intravenous iron, it is usually tolerated well. Usually, allergic reactions can be medicated beforehand. Response to treatment is dependent on how iron deficient one is, and if there are other chronic illnesses.

Risk Factors for Anemia

jboba: Could it be possible that my low body weight is making me especially sensitive and causing a mild case of anemia to feel much worse?

Dr__Horwitz: If your low body weight is due to an eating disorder or to other chronic illness, it may make the anemia worse and make you more sensitive to its effects.

chloer: What makes a person have a high risk for anemia?

Dr__Horwitz: There are certain kinds of anemia, like sickle cell anemia, that are inherited. There are many illnesses, like kidney failure or certain chronic infections that are associated with anemia. A person with ongoing blood loss is at risk. There also is a long list of medications which can cause anemia in some people.

Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic expert, Dr. Leonard Horwitz is now over. Thank you Dr. Horwitz for taking your time to answer our questions today about Ironing Out the Problems with Anemia.

Dr__Horwitz: Thank you for joining me. I enjoyed answering your questions. If you want more information, please call our Cancer Answer line, which also handles hematology. You also may check clevelandclinic.org/webchat for other programs like this.

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